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What does the future of advanced healthcare technology look like in a Patients First world where patients as health consumers have become lobbyists for web information, mobile access and more control of their healthcare records? Heading into RSNA 2012 with a Patients First theme – we find ourselves thinking about this question… and thinking about our OEM partners and radiologists needs.

The Patients First movement puts pressure on technology leaders to focus on what patient’s rank highest among their demands: ease of access. But the ResolutionMD product team at Calgary Scientific asks a bigger question: With all of the technology, web and wireless connectivity that we have in the world – how can we go beyond access in healthcare?

We think in terms of patient and physician needs with three themes etched in our minds:

Usability, Simplicity and Mobility

Expanded User Community

Connecting and Collaborating

We walk around with a picture in our head something like this:

Mapping our ResolutionMD product development roadmap also involves overlaying different moving parts (yeah, this isn’t easy, and you never get to mastery) – 1) the evolution of human behaviors: doctors, patients our partners, hospital and clinic leaders 2) the evolution of software, infrastructure networking and data access, 3) the evolution of healthcare delivery, collaborative care, diagnosis and integrated facilities and 4) the evolution of economics including affordability of hardware, government healthcare funding and insurance payments and 5) the evolution of accreditation and regulation including FDA-clearance but also increasing regional and national healthcare standards and goals.

While as little as five years ago the advantages of mobility were just arriving in medical, today doctors including radiologists have expectations of mobility like the Patients First community. Doctors desire look up control and anywhere access to complete patient information. But more than that, physicians today are demanding efficiency, collaboration and access applied to accurate diagnosis of patient treatment.

What we observe working with our luminaries and watching physicians at work…

iPads are the device most in use

rapid scrolling through studies and looking at side-by-side onscreen comparisons was most common activity

What we hear physicians want next…

“…One app combining all reports – that would replace the stethoscope.”

“…Embedded voice dictation …. that would give God-like status for the Rad.”

“We are often separated from our laptop and tablets, but never from our phones. Don’t stop updating for iPhones.”

“…Pay-for-use specialty treatment apps”

On site experiences with doctors and our luminary partners inspire our products and everyone at our Calgary Scientific.

Heading into RSNA 2012 with its Patients First theme, we are preparing questions to ask radiologists how we can help them put Patients first…. but also put Radiologist First. We want to learn how we can help radiologists go beyond how they perform healthcare today. That may mean going beyond the reading room, or going beyond one opinion, or going beyond the confines of their current case load and even their current incomes.

Our booth is 6244, South Hall A, at RSNA – book a time to come visit with us.

In the world of medical device development, speed is king. Just as people want to communicate instantaneously and get their news as it’s happening, they also want to understand the state of their own health. Unfortunately, answers in medicine don’t always come at the speed of light. But that doesn’t mean they can’t!

Emerging technologies are bridging the gap between test and diagnosis in an effort to get patients faster, more personalized care. Doctors, hospitals and even health systems are eager to put these products to work–once they’re sure the tool is effective, efficient and perhaps most of all, safe to use in an area as critical as health.

Naturally, the introduction of these new tools needs to be regulated. Or at least, that’s what most would expect. Despite numerous accreditations available to manufacturers of medical devices, many chose to forgo the process. And believe me, it’s definitely a process. ResMD would know. We’ve been through them all.

Canada

In Canada, your organization needs to first be certified through the International Organization for Standardization, or ISO. Standard 13485 is the one you’re looking for. It governs medical device manufacturers. Getting the 13485 involves having a third party review of all the documentation that supports your design and product development, quality assurance, testing, post-market follow-up and risk analysis. Then an auditor pays you a visit to make sure what’s on paper matches what’s on the ground.

If all goes well, you get an ISO certificate which you then send off to Health Canada with copies of basic documentation about your product. Health Canada issues your license and for $100 a year, your product gets to stay on the market.

Across the pond, the European Union regulates medical devices under aptly-named legislation called the medical device directive. Your systems are reviewed by a third-party company, called a notified body. Then, provided everything is up to snuff, you’re allowed to use the CE mark of approval on your device (flip over your iPhone and you’ll see which one we mean).

Health Canada’s licensing and Europe’s CE marking are both fairly straight-forward endeavors. And unless there’s an incident with your product, you can carry on merrily providing the medical world with a device that saves time and improves outcomes.

United States

The jurisdiction that presents the greatest challenge is the United States. Each time you apply, you send in thousands of dollars and a forest’s worth of paperwork with the hopes of obtaining a clearance letter from the Food and Drug Administration. One of Calgary Scientific’s recent submissions was about three inches thick! What’s more, the review period takes 90 days. More if the FDA has questions.

Needless to say, getting an FDA clearance letter is a big win. It’s one thing for us to say our solution is trustworthy, effective and secure. It’s another to have clearance from a regulatory body that gives whole new meaning to the idea of paperwork.

But does having the most daunting process mean you have the best? Industry players would be hard-pressed to say yes. On a recent trip to Boston for the AdvaMed conference, the CEO of a multi-billion dollar medical device manufacturer said his company can get a product on the market in Europe two to three years ahead of the US all because of the regulatory burden. As such, the push for improvements to the US accreditation system remains one of the highest priorities among manufacturers.

Seeking efficiency

Back in 1992, industry leaders and government representatives came together to form the Global Harmonization Task Force (GHTF). The idea was to find a way to coalesce the standards across jurisdictions. As a result, the FDA is starting to recognize the value of ISO standards. But the clearance process for medical devices hasn’t really changed.

In the meantime, the GHTF has become largely a discussion amongst regulators with few if any industry representatives at the table. Now more than ever, manufacturers need to forge the relationships that allow us to be part of the dialogue. We are the folks on the frontiers of new development. It’s our responsibility to keep the agencies apprised of where we see technology heading. Working together, we can ensure the clearance process is thorough, efficient and safe, so practitioners around the world have access to faster, better technological tools.

This post is part of a series on the Top 5 Trends Changing the Game in Global Healthcare IT. We encourage you to read the others:

On October 3, at the Cybera Annual Summit in Banff, Calgary Scientific will be on a panel exploring Big Data in Healthcare in Canada alongside leaders from OKAKI Health Intelligence, Siksika Health Services and University of Ontario Institute of Technology.

So what’s the big deal about healthcare data?

A $34 Billion market is Big

As Bloomberg recaps, “The so-called Big Data business has already permeated other industries and generated more than $30 billion in revenues last year, according to research firm IDC. It’s expected to grow to close to $34 billion this year in part because of increased use in the health-care industry.” Investment is spurred on in part by the Obama administration’s $14.6 billion program launched in 2009 to encourage adoption of electronic medical records.

Is the barrier to better healthcare truly more data?

At the same time investors and analyst are counting the money, luminaries and researchers including those at Stanford Medicine are raising concerns: “… the magnitude of the data, the speed at which it’s growing and the threat it could pose to individual privacy mean mastering “big data” is one of biomedicine’s most pressing challenges.”

So the opportunity in for Big Data in Healthcare is not just to create more access to information but to look at how that access can truly aid in the speed and effectiveness of healthcare treatment. How does big data actually help healthcare providers get better at rapid diagnosis and saving lives?

Collaboration is key – think Bigger than one omniscient Doc

When you listen to perspectives from frontline physicians, including Dr. Brian Goldman’s TED Talk “Doctors make mistakes. Can we talk about that?” which has had 550,000 views on TED.com, it becomes clear the opportunity of Big Data is bigger than more access, more accurate record viewing and a whole patient picture. The Big Data opportunity in medicine is to develop a better way for physicians to mine and be served by data.

Greater data access needs to be combined with better ways of assessing and diagnosing patients. Critical in the mix is collaboration – expecting not just one doctor to diagnose faster but to connect her or him to residents and specialists for a faster second opinion that may truly be the life saver. And more than serial reviews – one doctor, then another – collaborative medical care needs to allow multiple physicians and healthcare Boards to look at a patient’s record at the same time, seeing each other control the images and record as they discuss approach and treatment.

This collaborative analysis of big data to improve treatment for a single patient is a major advance, but consider the broader opportunity to pool patient records and analyze the data collectively. This is the arena of Comparative Effectiveness Research (CER) which the American Recovery and Reinvestment Act of 2009 has earmarked $1.1 billion for investment. Paul Cerrato, Editor of InformationWeek Healthcare, proposes CER is healthcare IT’s next big challenge, where technology must unlock big data to uncover new treatment options and lower the cost of such discoveries. Now you have multiple physician teams, treatment Boards, clinical trials, luminary hospitals and researchers all able to benefit from a more total view of healthcare issues than ever before possible, with technology that connects the brightest specialists from all over the world and lets them interact with each other to collaborate on medical discoveries.

As Mike Snyder, chair of genetics at Stanford Medicine commented in the Summer 2012 Stanford Medicine magazine, “We’ve been so focused on generating hypotheses, but the availability of big data sets allows the data to speak to you. Meaningful things can pop out that you hadn’t expected.”

There will be lots of discussion at Cybera about big data security, privacy and the challenges of interconnected healthcare, which include structural obstacles around data infrastructure, multi-vendor systems and technologies. The old paradigm of trying to push copies of data sets to large, centralized repository locations has proven massively costly, and highly ineffective, even in socialized healthcare systems where the data is controlled by government versus different groups of competing healthcare providers. I look forward to seeing more changes in technology to aid physicians in not just doing more of the same, faster, but truly achieving a single view of a true patient record and realizing a broader collective healthcare vision that spans across healthcare globally.

Use cases that inspire us:

Dell applying cloud technology for personalized medicine

Dell is providing computing power for two research centers to try and treat a particular form of pediatric cancer based on each child’s specific genetic profile.

Stanford Medicine’s “Omics Study” of human genetics

Led by chair of the Stanford’s Genetics Department, Michael Snyder, PhD, the unprecedented study, termed an integrative personal genomics profile, or iPOP, generated billions of individual data points about Snyder’s health, to the tune of about 30 terabytes (that’s about 30,000 gigabytes, or enough CD-quality audio to play non-stop for seven years).

The way we talk about the internet often suggests the intangible: we speak of being ‘virtual’, of zeroes and ones, and the Cloud. But of course, it has a physical structure that transports all our data. It’s this world that journalist Andrew Blum explores in his book Tubes: A Journey to the Center of the Internet.

On this episode of Spark: Robot Pebbles, the Loyalty Leap, and Online Hoaxes. Click below to listen to the whole show, or download the MP3 (runs 54:00).

You can also listen to individual stories below.

Learning to Lie Online

Mills Kelly is the director of the Global Affairs program and an associate professor of history at George Mason University. He teaches a controversial course called “Lying About the Past” where students create a hoax and “turn it loose on the internet.” He says this course helps students become critical thinkers and more discerning consumers of information from the web. (Runs 10:13)

Bryan Pearson is the CEO and president of LoyaltyOne, the people behind Air Miles. He’s the author of “The Loyalty Leap” which looks at the collection of customer data and the challenges companies face in trying to figure out how to use that information in ways that are relevant and not creepy. (Runs 8:54)

We’ve talked a lot about whether or not learning computer programming language is as essential a skill as learning to read or write. Back in October Program or Be Programmed author Douglas Rushkoff gave us his take, and last week’s show we heard from a middle school teacher who sees the benefits of kids learning code every day. Enter Carlos Bueno, a Software Engineer at Facebook and the author of Lauren Ipsum a book that introduces coding to kids by using metaphor. (Runs 7:49)

What if the next time you needed two of something, you could just throw an object into a bag and the little robo-pebbbles inside would just morph into a duplicate for you? It sounds like something from the Terminator, but it’s actually technology that’s being developed in Kyle Gilpin’s lab at MIT. Gilpin and his post-doc supervisor Daniela Rus have developed robot pebbles that can communicate, self-assemble, and sculpt replicas of the object they surround. Whoa. (Runs 8:25)

They tweet, blog, and even dream: Weavrs are the next generation of social bot. They’re a kind of semi-intelligent algorithm that mimics human behaviour to a startling degree. Nora asks David Bausola, the creator of the Weavr platform, what this technology means for the future of marketing. (Runs 8:04)

Mills Kelly, a history professor at George Mason University, had a problem. His students just didn’t seem to understand they can’t believe everything they read online, it’s a common lament for educators these days. Then he came up with an idea for a special history course. In Lying About the Past, students learn about historical hoaxes, and then create a hoax of their own and “turn it loose on the internet.”

Nora speaks with Mills Kelly about why he thinks it works to have his students actually create hoaxes in order to learn about information literacy.

Robot comedians, robot game designers, robo-readers. On Spark, it seems like we’ve explored almost every type of robot. Until we heard about robot pebbles. Yeah that’s right, robotic pebbles that can communicate, self-assemble and morph into any object they surround.

We all know companies collect lots of data about their customer base. How can they use data effectively without violating our privacy, or, more basically, creeping us out? What are the Golden Rules for respecting customer data and earning loyalty? Are all bets off when it comes to the online environment, where collecting information without transparency seems to be the default? These were some of the questions on my mind when I interviewed Bryan Pearson recently. He’s President and CEO of LoyaltyOne (the people behind Air Miles), and the author of The Loyalty Leap: Turning Customer Information into Customer Intimacy.

There’s been a lot of talk about whether or not learning computer programming language is as essential a skill as learning to read or write. Back in October 2011 we talked about it with Program or Be Programmed author Douglas Rushkoff as well as here, and again on last week’s Spark.

It’s a fascinating subject, and last week Nora did an interview with Carlos Bueno (which you’ll hear on our upcoming show in a few days). Carlos is a Software Engineer at Facebook and the author of Lauren Ipsum a book that introduces coding to kids by using metaphor.

Other things we think are cool about the book: Carlos’ wife Ytaelena Lopez did the illustrations. And for every copy that is sold, another copy will be donated to schools, libraries, and educational programs.

On this episode of Spark: Robo-readers, Livehoods, and Pre-crime Screening. Click below to listen to the whole show, or download the MP3 (runs 54:00).

You can also listen to individual stories below.

How Alive is your Neighbourhood?

The Livehoods Project is described as “a new way to understand a city using social media.” Justin Cranshaw is a researcher at Carnegie Mellon where they are collecting data from check-ins like Foursquare and then putting that data onto a map, so you can see where people are “checking in” and see what that information tells you about a particular area. They’ve been doing American cities (New York, San Francisco) and just launched their first Canadian city, Montreal (Runs 10:09)

It sounds like something from the movie Minority Report, but the US Department of Homeland Security is researching ‘pre-crime’ technology to screen for people who may be about to commit a terrorist act. Alexander Furnas is a journalist who has given the technology a lot of thought. He considers whether technology like this could actually work. (Runs 8:11)

CAPTCHAs are the set of squiggly numbers and letters that you are expected to decipher on websites, in order to prove you’re a human and not a spambot. Recently on Spark, we talked about the fact that CAPTCHAs are getting more difficult for humans to figure out. What though, about visually impaired computer users? Turns out the ‘audio’ CAPTCHAs aimed at people who are visually impaired are a user interface “fail”. Nora talks to Brian Gage, a blind computer user, about the problem.(Runs 5:37)

Mark Shermis, Dean of Education at the University of Akron, has a keen interest in automated essay scoring programs. He’s currently overseeing a contest to find the best robo-reader, a software program used to grade essays and has recently conducted a study on the technology. How could this software change the way students learn? We also hear the personal story of Spark intern Laura Anderson, who wrote an essay tailored specifically for a robo-reader and got a perfect score. (Runs 9:13)

Middle school teacher Tannis Calder doesn’t have a background in computers, but she’s become a huge advocate for getting kids to learn computer programming skills in the classroom. She uses an easy-to-use computer programming language called Scratch, designed for kids by MIT. (Runs 7:59)

A while ago on Spark, I talked to Rohan Gunatillake, about meditation and digital culture. In our interview, he talked about the need to design digital technology that supports attention and focus, rather than distraction. That had me thinking: what would that actually look like?

Turns out researcher Roel Vertegaal has been working on just such an issue. He’s an associate professor in Human-Computer Interaction at Queen’s University. He coined the term “attentive user interface” to describe this sort of design for attention and focus.

You can think of a neighbourhood as a fixed boundary of streets, but for many of us, what we think of as our neighbourhood is more organic than that. It’s the places we hang out – our stomping grounds – which may not conform to the way our city defines a neighbourhood. Researchers at Carnegie Mellon University are experimenting with the idea of “livehoods“. They’re using people’s FourSquare check-ins to plot these more dynamic neighbourhoods. If the same people check in at cafe A and store B, but not store C right across the street, store C is in a different livehood. I interviewed Justin Cranshaw, co-creator of Livehoods, and a doctoral student at Carnegie Mellon, about the project.

They have just published their first Canadian livehood map, Montreal. You can find it here. I used to live in Montreal, but that was a LOOOONNNNG time ago, and I’ve only been back to visit occasionally more recently. Some of the patterns on the map made a lot of sense to me, but some didn’t, suggesting perhaps the ways those areas that have changed since my Montreal days. I’d love to hear what Montrealers think of the Montreal Livehood. Does it square with how you use your city? Please leave your comments below.

This week on Spark’s regular, over-the-air radio broadcast, you’ll hear Spark 157: Sensors, Predictors, Recognition Software – oh my! which first aired back in October 2011. But you won’t hear Spark 157 this week on the podcast, because we’ve promised no more podcast repeats. We’ll be back with a brand-new episode of Spark next week, on June 3rd.

In the meantime, you can listen to the original broadcast of the whole show below (runs 54:00).

[Audio clip: view full post to listen]

You can also listen to individual stories.

Facial Recognition

Jennifer Steeves

Recent advances in facial recognition technology are giving us the feeling of being much closer to a “Minority Report” reality. But how close are we really? Psychology professor Jennifer Steeves of York University explains how human beings recognize one another compared to facial recognition software. And Alessandro Acquisti from Carnegie Mellon University reveals some surprising research into how regular recognition tech can identify “anonymous” people. (Runs 22:38)
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Ok, Moore’s Law. It is… um… we’ll let you read up on it on your own! We’re interested in someone who proposes a modification of it. Jonathan Koomey is a consulting professor at Stanford University, and his research shows that it’s not processing power that doubles every 18 months, it’s energy efficiency. And in a world dominated by mobile devices and mobile batteries, efficiency may become the new power. (Runs 3:39)
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No two snowflakes are alike, no two people are the same… right? You may think you’re unique, but it turns out you’re awfully predictable. Jure Leskovec is an assistant professor of computer science at Stanford, and he analyses past human behaviour online to predict future outcomes. And he’s discovered he can correctly predict who your next friends on Facebook will be. (Runs 9:57)
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What happens when cities can monitor and respond to the people who live in them? There is no end to the Spark obsession with this question. Ayesha Khanna, director of the Hybrid Reality Institute, talks to Nora Young about the potential, and the challenges of smart cities, and what becomes possible when sensors are embedded everywhere. (Runs 12:20)
[Audio clip: view full post to listen]

On this episode of Spark: Phone Fonts, POV video, and Long-distance Love Tech. Click below to listen to the whole show, or download the MP3 (runs 54:00).

You can also listen to individual stories below.

Game CAPTCHAs

We’ve all encountered those squiggly distorted letters on websites that you have decipher in order to prove you are, in fact, a person. But what if instead, you could play a short little game to prove you’re not a bot? Nora speaks with Reid Tatoris, co-founder of Are You a Human – a company that’s developed a game-based human verification system. (Runs 7:45)
[Audio clip: view full post to listen]

The trend toward sophisticated and easy-to-use point of view technology is heating up, and Spark contributor Cathi Bond stops by with a pair of POV video glasses to show Nora how you can now make high definition movies while walking around…and what the implications for privacy are. (Runs 6:40)
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A lot is going on in New York City in the summer, but nothing quite like the second annual Robot Film Festival on July 14 and 15, a celebration of robots on film. Heather Knight is co-founder of the fest (she was on Spark a few weeks back about her robot comedian) and she tells us about the festivals goal to seek insight into robot character through storytelling and showing the positive side of robots on film. (Runs 6:23)
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This week, Bill C-11, the copyright reform bill, came out of committee and now awaits third reading. We thought it was a good time to check up on what’s happened since the bill was originally introduced in the fall. And that’s where David Fewer, Director of the Canadian Internet Policy and Public Interest Clinic, comes in. (Runs 5:34)
[Audio clip: view full post to listen]

In some ways, being in an “LDR” or Long Distance Relationship, has never been easier. From webcams to instant messaging, it’s cheap and easy to keep in constant touch. Researcher Carman Neustaedter has been looking into how couples use technology to stay in touch, and whether it can ever truly be as good as actual physical presence. (Runs 9:25)
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How do you design typeface that is easy to read on the small screens of our portable tech? Just ask Steve Matteson! He’s designed successful fonts for Android phones and the Nook ereader. Nora talks with him about what it takes to make a font that really fits. (Runs 8:50)
[Audio clip: view full post to listen]

On this week’s show, writer and Spark contributor, Cathi Bond brought us the story of Pivothead “video recording eyewear”: a camera nested in a pair of eyeglasses that can capture high definition, point of view video. Cathi sees it as an example of our growing trend towards capturing and sharing video, and of a possible future where people become entertainment and communication ‘hubs’. But how well do these glasses perform, anyway, and what do they look like? I took a working prototype of the Pivothead glasses out for a spin around the Spark office, shooting video and recording narration using the Pivothead’s audio recording capability. What do you think? What likely uses will we see for point of view video down the road?

If you like this video, you might also like Cathi Bond on the Sony 3D visor

These days we spend a lot of time reading text on computer screens and small mobile devices. Steve Matteson is Creative Type Director at Monotype Imaging and he thinks a lot about how to make that digital text legible and easy to read.

You’ll have noticed Steve’s handiwork in Windows, there’s a typeface family called Segoe which is the brand typeface and used in the user interface. He also designed the typefaces for the Xbox and the Xbox 360. And if you use an Android phone, you’ll be familiar with his Droid Sans and Serif typeface families.

Nora talks to Steve about the challenges in designing fonts for our portable technology and whether there’s such a thing as a “bad font.” You’ll notice Nora is pretty keen about fonts herself, watch for her dropping terms like “kerning”!

This week, Bill C-11, the copyright reform bill, came out of committee and now awaits third reading. We thought it was a good time to check up on what’s happened since the bill was originally introduced in the fall. I just spoke with David Fewer, Director of the Canadian Internet Policy and Public Interest Clinic.

On this episode of Spark: Descriptive Cameras, Bio-hacking, and Forgiving Bad Design. Click below to listen to the whole show, or download the MP3 (runs 54:00).

You can also listen to individual stories below.

The Descriptive Camera

Is a picture worth a thousand words? According to Matt Richardson: not really. Richardson is the creator of the Descriptive Camera. The device is like a Polaroid, but with words — instead of producing a photo, the camera prints out a hand-crafted text description of whatever it sees. (Runs 6:22)

One day, Jamie Malcolm and Mark Winter left a disposable camera in Convent Garden. The camera had instructions to take a photo, relocate and leave behind for the next person. 43 days later it returned, and from there the Camera Obscura project was born. Now they want to “test the good nature, trust and creativity of the world” by leaving cameras in places outside of England. (Runs 6:06)

Hendrik Knoche is a computer scientist, specializing in human-computer interaction, and he’s been working with farmers in rural India to create smart phone apps so they can crowdsource agricultural information. The challenge is that many farmers in rural areas are illiterate, so how do you create an app that’s easy and accessible to use? (Runs 8:33)

Sanjay Arora is the founder of Exponential Labs, a Toronto-based software startup. There’s a lot of buzz building about one of their projects, Million Short. It’s a search engine that delivers results to you, after it knocks off the top one million most popular websites. (Runs 6:13)

A few weeks ago on Spark, we heard how scientists at the University of Ottawa were working to create designer organs (the kind in our bodies!) that could communicate via Twitter. This kind of bio-tinkering seems an awful lot like what’s going on in the DIY-bio movement. Yes, Do-it-yourself bio-hackers do exist, and they say if you’re an actual scientist, you can’t be in the club! Spark contributor Sonya Buyting tells us more. (Runs 7:19)

Henry Petroski is a professor of civil engineering and history, and an expert in understanding engineering failures. In his book To Forgive Design, he says we need to understand failure in order to succeed. (Runs 9:37)

You know, Nora Young has a new book out now called The Virtual Self: How Our Digital Lives Are Altering The World Around Us, all about the way more and more of us are keeping track of our everyday lives. There are tons of digital tools to help us record, aggregate and archive everything from our morning runs to our web-browsing habits. Basically, how many of us are converting our daily experience into statistics. In her book, Nora looks at what all this digital self-reporting means when it comes to transparency and privacy.

And we’ve got five copies to give away! Just leave us a comment here with your thoughts on life-logging or personal data collection, and next week we’ll randomly select the winners from all the comments.

I just finished interviewing Sanjay Arora, founder of Exponential Labs, a Toronto-based software startup. There’s a lot of buzz building about one of their projects, Million Short. It’s a search engine that delivers results to you, after it knocks off the top one million most popular websites. Your search won’t turn up results with Facebook, YouTube, or Wikipedia. You can also customize it, so that it knocks, say, only the top 1,000 sites off, or you can configure the settings so that it lops off the most popular sites except Facebook, YouTube, etc.